Parkview Manor Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Weimar, Texas.
- Location
- 206 N Smith St, Weimar, Texas 78962
- CMS Provider Number
- 675922
- Inspections on file
- 25
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Parkview Manor Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with COPD, paraplegia, depression, dementia, and nicotine dependence, who was cognitively intact per BIMS, experienced ongoing verbal and emotional abuse and intimidation by an LVN. Documentation and interviews showed the LVN told the resident to get off her hall and not return, while the resident reported the LVN had popped her in the mouth. The resident and staff reported that the LVN spoke rudely to the resident, refused to take her on smoke breaks while taking other smoking residents, restricted her from approaching the nurse’s station, grabbed and turned her motor wheelchair away from the area, and prompted the removal of the resident’s cigarettes from the nurse’s station. The resident altered her routes within the facility to avoid the LVN and initially felt bad and sad about being excluded from smoke breaks. Despite these reports and observations, the facility did not update the resident’s care plan to reflect the abuse allegations or recognize the pattern of verbal and emotional abuse and intimidation.
A resident with dementia, multiple chronic conditions, and impaired communication was transferred to a hospital for stroke-like symptoms, but the responsible LVN did not complete required change-of-condition and discharge documentation. Family reported they were not officially notified by the facility of the resident’s change in condition or transfer, and staff interviews confirmed there were no timely clinical notes detailing the reason for transfer, physician and family contacts, or how and when the resident left. The interim DON and ADM stated that the absence of an SBAR prevented the discharge summary from being generated and kept the discharge from appearing on the ADT report until a discharge summary was completed later after surveyor intervention.
A resident with paraplegia, COPD, dementia, major depressive disorder, and other psychiatric conditions, and with intact cognition per BIMS, alleged that an LVN struck her in the mouth following earlier documented verbal conflicts and agitation between them. Nursing notes described the resident’s verbal outbursts and an evening hallway argument where the LVN yelled at the resident and told her to leave the hall, with no immediate injuries or distress noted. After the resident later reported being "popped" in the mouth, the DON completed a physical assessment and notified the responsible party and MD, but the facility did not conduct a psychosocial assessment or risk assessment, and the resident’s care plan was never updated to reflect the abuse allegation, resulting in a failure to ensure necessary psychosocial care and services.
A resident with dementia, muscle wasting, gait abnormalities, and impaired cognition experienced a significant change in condition with stroke-like symptoms that led to an emergency hospital transfer. Family members reported they were not promptly informed of the resident’s worsening condition or discharge, and staff accounts described concerns raised by a family member, a med aide’s difficulty administering medications when the resident was unusually sleepy, and an elevated BP that prompted an LVN to call 911. Despite this, the resident’s clinical record lacked an SBAR/change-of-condition report, timely nursing progress notes, and a contemporaneous discharge summary documenting assessment findings, vital signs, notifications to the MD and family, and the rationale for transfer. The interim DON and administrator confirmed that the required documentation was not completed by the responsible LVN and that the discharge was not properly reviewed, resulting in incomplete and inaccurate medical records related to the resident’s change in condition and hospital transfer.
Surveyors found black, moldlike substances on ceiling tiles in multiple areas, with staff interviews revealing that maintenance had lapsed after the previous director left. An LPN and anonymous staff described ongoing mold issues linked to leaking A/C systems and inadequate repairs, including covering up mold with paint. The facility lacked a policy on physical environment, and the administrator questioned the identification of mold when shown evidence.
A resident with severe cognitive impairment was physically abused by a staff member in an LTC facility. The resident, who was agitated and confused, hit a medication aide (MA) during care, and the MA reacted by hitting the resident back. This incident was witnessed by an LVN and involved a CNA. The resident's care plan advised against unnecessary physical contact due to a history of trauma, but this was not followed. The staff had prior training on abuse and neglect, yet the incident occurred, indicating a failure in applying this training.
The facility failed to ensure a safe, clean, and homelike environment in two shower rooms. Observations revealed soap scum, hard water stains, and a reddish substance in the first shower room, while the second had a missing tile, mildew, and high water temperature. Despite cleaning efforts, stains persisted, and the facility lacked water temperature logs. No residents were reported injured.
The facility did not maintain sufficient RN staffing on several weekends in Q2 2024 due to its remote location, leading to a lack of coverage on specific dates. This shortage was acknowledged by the DON and attributed to difficulties in attracting weekend RNs. The facility's policy requires 24/7 RN or LPN coverage, which was not met.
The facility failed to properly label opened food items in the refrigerator and stored a dented can of tomatoes with other canned goods, contrary to professional standards. This oversight was acknowledged by the Dietary Manager and poses a risk for foodborne illness.
The facility failed to maintain appropriate water temperatures in two shower rooms, with one room having water too cold and another too hot, exceeding safe limits. The Maintenance Supervisor, new to the role, confirmed the temperatures and acknowledged the absence of required water temperature logs. Despite no reported injuries, the facility did not adhere to its policies for regular temperature checks, compromising resident safety.
A resident with chronic conditions and paraplegia was found without access to a call light, which was on the floor under the bed. The resident's care plan did not address call light use, and staff were unaware of how it became inaccessible. The DON highlighted the importance of call light accessibility, which is monitored during morning rounds.
A resident with muscle wasting and feeding difficulties was not provided with a built-up spoon and straw during meal service, as required by her care plan. Instead, she received a regular fork, despite her request for a regular fork due to discomfort with the built-up spoon. The Dietary Manager acknowledged the oversight, which could impact the resident's ability to eat and drink.
A facility failed to ensure safe and sanitary storage of food items in a resident's personal refrigerator. Observations showed unlabeled and undated sliced summer sausage, confirmed by a CNA and the DON. The facility's policy requires perishable foods to be labeled and dated, but this was not monitored by the night shift nurses.
A facility failed to accurately document a resident's code status, with discrepancies between the admission record, consolidated orders, and care plan conference. The resident was documented as full code in some records but incorrectly as DNR in a care plan conference. The MDS coordinator acknowledged the error, noting that charge nurses rely on the code status book and orders for accurate information.
Failure to Protect a Resident From Ongoing Verbal and Emotional Abuse by an LVN
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and emotional abuse and intimidation by an LVN over an extended period. The resident was an older female with COPD, paraplegia, muscle weakness, major depressive disorder, nicotine dependence, insomnia, dementia without behavioral disturbance, psychotic/anxiety/mood disturbance, and wheelchair dependence. Her care plan reflected depression and impaired cognitive function due to dementia, and her most recent MDS showed a BIMS score of 14, indicating intact cognition. The care plan identified her as a smoker but did not include any documentation of abuse allegations. On one documented occasion, a progress note dated 11/10/2025 at 9:00 p.m. reflected that LVN B witnessed an argument in which LVN A told the resident, "You need to get off of my hall and go back down to your room right now," and, "I am not your nurse, and I want you off of my hall and don't comeback down here." The resident reported to LVN B that LVN A had "popped her in the mouth," and LVN B completed a head‑to‑toe assessment and notified the physician. The allegation was reported to the ADM/abuse coordinator and to the State Survey Agency, and the facility’s investigation and a prior state survey found the physical abuse allegation unsubstantiated; however, the verbal interaction and the resident’s report of being struck were documented. The interim DON later stated that this interaction was not considered sufficient evidence to substantiate abuse. Multiple interviews described a pattern of ongoing intimidating and exclusionary behavior by LVN A toward the resident from the time LVN A began working at the facility until her termination. The resident stated that when LVN A was on shift, she had to avoid the nurse’s station because LVN A would stop her, grab her electric wheelchair controller, and turn her around, and that LVN A refused to take her out for smoke breaks. The resident reported that her cigarettes were moved from the 300‑hall nurse’s station because LVN A did not want them there, and that she had to take a longer route to therapy to avoid passing the nurse’s station when LVN A was present. She described initially feeling bad and sad while watching LVN A and other residents smoke without her and said she adjusted by avoiding contact, communication, and proximity to LVN A. Staff interviews corroborated that LVN A spoke rudely to the resident, denied her smoke breaks, and restricted her from going near the nurse’s station when LVN A was on shift. The HS stated that LVN A intimidated the resident by making rude comments, telling her she was not allowed near the nurse’s station, and refusing to take her out to smoke, requiring other staff to come off the floor to do so. The HS also reported that the resident would travel the long way around the facility to avoid LVN A and that the resident’s cigarettes were moved from the nurse’s station to the memory care nurse’s station after LVN A objected to them being there. The DON acknowledged having to counsel LVN A about her attitude and unprofessional interactions and stated she had redirected LVN A after LVN A told the resident she could not drive her motor wheelchair around the nurse’s station because LVN A did not want the resident around her following the earlier abuse allegation. Despite these observations and reports, the facility did not update the resident’s care plan to reflect the abuse allegations or the ongoing intimidation and did not recognize or substantiate the pattern of verbal and emotional abuse and intimidation toward the resident.
Failure to Complete Timely and Accurate Transfer/Discharge Documentation for a Resident Sent to Hospital
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete, accurate, and timely transfer/discharge documentation for a cognitively impaired resident who was sent to the hospital for stroke-like symptoms. The resident was an elderly female with multiple diagnoses, including depressive episodes, GERD, anemia, insomnia, hyperkalemia, and diaphragmatic hernia, and had dementia with impaired cognition (BIMS score of 4), communication problems, unclear speech, ADL self-care deficits, and limited mobility. The resident’s face sheet showed no discharge date, and her care plan and MDS confirmed significant cognitive and functional impairments. According to family and staff interviews, an LVN observed stroke-like symptoms and ultimately called 911 to transfer the resident to the hospital, reporting that the resident had shown such symptoms for approximately 24 hours without the family being notified. Family reported they did not receive an official call from the facility about the change in condition or transfer, and no one from the facility contacted them to check on the resident’s status after the transfer. The attending physician later stated that she had been called by the LVN and had directed an immediate transfer to the hospital due to stroke-like symptoms. Multiple staff, including the HS, LVN C, the Med Aid, the interim DON, and the ADM, confirmed that the responsible nurse (LVN A) did not complete required documentation related to the resident’s change in condition and discharge. Specifically, there was no SBAR, no change-of-condition note, and no discharge summary completed at the time of transfer, and the resident’s clinical record contained no notes reflecting physician and family contacts, the reason for transfer, or how and when the resident left the facility. The interim DON and ADM stated that the missing SBAR prevented the discharge summary from being triggered and kept the discharge from appearing on the ADT report within 24 hours. The discharge summary was only completed later by the interim DON after surveyor intervention, confirming that the facility failed to ensure timely and accurate transfer/discharge documentation to support continuity of care.
Failure to Complete Psychosocial Assessment After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with professional standards of practice. The resident was an older female with paraplegia, COPD with acute exacerbation, major depressive disorder, dementia, psychotic/anxiety/mood disturbance, and nicotine dependence. Her care plan addressed impaired cognitive function related to dementia and the need for antidepressant medication for depression, but it did not include any focus or interventions related to an abuse allegation. A quarterly MDS showed a BIMS score of 14, indicating intact cognition. On one day in November, nursing notes documented multiple interactions between the resident and LVN A. In the morning, LVN A recorded that the resident became verbally abusive and used a racial slur toward her when upset about a delayed smoke break; LVN A then requested that LVN B take the resident out for smoke breaks. Later that evening, LVN B documented a cognition/behavior/agitation event in which LVN A yelled at the resident in the hallway, told her to get off the hall and return to her room, and stated she was not the resident’s nurse and did not want her on that hall. The note indicated that arguing occurred, but that the resident and LVN A went their separate ways with no injuries, pain, or signs of distress or discomfort observed at that time. Subsequently, a nursing note by the DON documented that, after this occurrence, the resident voiced that LVN A had “popped her in the mouth.” The DON performed a head-to-toe assessment and notified the resident’s responsible party and the physician. Additional documentation by LVN B indicated no adverse skin issues and described the resident as having patterned verbal behavior with no adverse mental, emotional, or physical effects. During interview, the interim DON stated that, despite the resident’s allegation of being struck, the facility did not complete a follow-up psychosocial assessment or any risk assessments to determine whether the resident had experienced psychological harm from the event. The administrator confirmed he was unaware that a psychosocial evaluation had not been completed following the abuse allegation and that the expectation had been for the social worker to initiate such an evaluation, which did not occur.
Failure to Document Resident Change in Condition and Emergency Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records and incident/change-of-condition documentation for a resident who experienced a significant change in condition and was transferred to the hospital. The resident was an elderly female with dementia, muscle wasting, gait abnormalities, and muscle weakness, who had an ADL self-care deficit and communication problems but was usually understood and usually understood others. Her Quarterly MDS showed a BIMS score of 4, indicating impaired cognition. The care plan identified limited physical mobility and use of antidepressant medication with risk for side effects. The resident’s face sheet showed she had been admitted to the facility with no discharge date recorded at the time of review. Family members and staff provided differing accounts of the events leading up to the resident’s transfer. One family member reported receiving a call from an LVN stating the resident had stroke-like symptoms and was sent to the ER, and later learned from the hospital that the resident had a stroke and was med-flighted to a higher level of care. This family member stated that the LVN told her the resident had shown stroke-like symptoms for about 24 hours without the family being notified, and that the LVN had instructed another nurse to monitor the resident for stroke-like symptoms before going off shift. The LVN reportedly told the family member she called 911 against facility protocol and was terminated for sending the resident to the ER without prior physician consent. The family member also stated that no one from the facility had officially notified her of the resident’s discharge with a change in condition or checked on the resident’s status. Multiple staff interviews showed that the resident’s change in condition and subsequent transfer were not properly documented in the clinical record. The HS reported being informed by the LVN that a med aide had observed the resident in and out of consciousness, but the HS questioned how the resident could have been unconscious for two shifts without any reports. LVN C stated that when a med aide relayed family concerns that the resident was not feeling well, she assessed the resident, found vital signs normal, and the resident stated she was fine; she then told the oncoming LVN to watch for changes. The med aide reported that during an evening medication pass, the resident was asleep, did not receive medications, and a family member expressed concern about the resident’s appearance; the med aide noted the resident appeared asleep with some whites of her eyes visible, asked a CNA about the resident’s status, and informed LVN C and then LVN D about the missed medications. The med aide stated there was a rumor that a family member spoke to LVN C about the resident’s condition and that no one checked on the resident for 12 hours, and that when LVN A came on shift, the resident’s blood pressure was 181/131, prompting the LVN to call 911. The interim DON stated that on the day of the change in condition, the resident required immediate transfer by ambulance to a higher level of care, and that as the resident’s nurse, LVN A should have completed an SBAR/change-of-condition report documenting the date, time, assessment findings, vital signs, medications, and notifications to the physician and family. The interim DON confirmed there was no SBAR, no discharge summary, and no nursing progress notes detailing or summarizing the resident’s need for hospital transfer or her condition at the time of transfer, and that the absence of the SBAR also affected the resident’s appearance on the ADT list and initiation of the discharge summary. The administrator reported that when a family member requested the resident’s clinical records, he could only provide the last hospital notes in the progress notes and that he did not have more detailed information because he had not obtained it from staff. He further stated that LVN A had not completed the required change-of-condition/SBAR documentation describing when, where, and why the resident was sent to the hospital. Physician documentation showed that a provider had assessed the resident the day before the event and noted no issues, and that later, the physician was informed by LVN A that the resident had elevated blood pressure and eyes rolling back, and directed the nurse to call 911 for immediate transfer due to stroke-like symptoms. The discharge summary for the resident was only completed and signed several days later, after surveyor intervention, confirming that the facility failed to contemporaneously document the resident’s change in condition and transfer in accordance with professional standards and regulatory requirements. The facility’s own admission, transfer, and discharge log reflected that the resident was discharged to an acute care hospital on the date of the change in condition, but the clinical record at that time lacked corresponding nursing notes, SBAR, or timely discharge summary documenting the resident’s status, assessments, and notifications. Staff interviews consistently indicated that LVN A, as the charge nurse, was responsible for completing the change-of-condition documentation and that this was not done. The interim DON acknowledged that it was the DON’s responsibility to ensure the charge nurse completed the SBAR and that the process “fell through” and the discharge was not reviewed. As a result, the resident’s clinical record did not contain complete and accurate information about the change in condition, the care provided, or the notifications made at the time of the emergency transfer, which the report states had the potential to affect all residents by compromising continuity of care, clinical decision-making, and resident safety.
Failure to Maintain Sanitary and Safe Environment Due to Mold Contamination
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by the presence of a black, moldlike substance on ceiling tiles throughout the building. Observations on multiple occasions revealed blackened ceiling tiles in several locations, including outside the Soiled Utility room, near resident rooms, across from the Therapy Gym, over a Nurse's Station, and in the Therapy Room. Interviews with staff indicated that the facility had been without a Maintenance Director for two weeks, and no one had performed necessary repairs or maintenance since the previous director's departure. The previous Maintenance Director had regularly cleaned and replaced affected tiles, but these tasks had not been continued. Additionally, the facility administrator questioned whether the substance was black mold and stated that repairs were being made as issues were identified, but acknowledged ongoing challenges due to the building's age. An anonymous interview revealed that staff were aware of extensive mold issues, particularly related to the air conditioning system, which had eroded drip pans and frequent leaks causing water damage to ceilings, walls, and light fixtures. The anonymous source also alleged that the administrator instructed the Maintenance Director to cover up mold odors with paint and to patch over visible mold rather than fully remediate it. The facility did not have a policy on Physical Environment available when requested, and a review of the Resident Rights policy indicated residents' rights to a dignified existence in an environment that promotes quality of life and protects their rights.
Resident Abuse Incident by Staff Member
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member. The incident involved a resident with severe cognitive impairment due to dementia, who was found on the floor by a medication aide (MA) and a certified nursing assistant (CNA). During the process of assisting the resident back to bed, the resident, who was agitated and confused, began swinging her arms and inadvertently hit the MA in the face. In response, the MA reacted by hitting the resident back in the face, which constitutes physical abuse. This incident was witnessed by a licensed vocational nurse (LVN) who was present during the event. The resident's care plan noted a history of trauma and advised staff to avoid touching the resident unless necessary for safety, indicating that the staff's actions were not in alignment with the care plan. The facility's failure to prevent this incident of abuse highlights a lapse in ensuring the safety and dignity of the resident. The staff involved had previously received training on abuse and neglect, as well as behavior management for residents, yet the incident still occurred, indicating a failure in applying this training effectively during the incident.
Deficiencies in Shower Room Cleanliness and Safety
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in two shower rooms, as observed during a survey. In the first shower room, there were issues such as soap scum and hard water stains on the tiles, a dirty shower mat with black stains, and a shower chair backrest with hard water stains. Additionally, a reddish substance was found under the shower chair. The Laundry/Housekeeper and Maintenance Supervisor confirmed these observations, noting that despite cleaning efforts, the stains remained. The water temperature in this shower room was recorded at 96.8 degrees Fahrenheit. In the second shower room, a tile was missing, and there was mildew buildup on the vent. The shower chair under the seat also had a reddish substance. The Maintenance Supervisor, who had started two weeks prior, noted that the water temperature in this room was 124.1 degrees Fahrenheit, which he acknowledged was too hot, preferring it to be no more than 110 degrees Fahrenheit. Interviews revealed that the housekeeper did not clean under the shower mat or the tiled walls and floors. The facility lacked water temperature logs, and the ADM/DON confirmed that no residents had suffered burns from the hot water. The facility's policy on resident rights emphasized the importance of a safe and clean environment.
Insufficient Weekend RN Staffing in Q2 2024
Penalty
Summary
The facility failed to maintain sufficient nursing staff to ensure resident safety and well-being during the second quarter of 2024. Specifically, the facility did not have registered nurse (RN) coverage on several weekends, including February 10, 11, 25, March 23, 24, 30, and 31. This lack of coverage was attributed to the facility's remote location, which made it difficult to attract and retain weekend RNs. The Director of Nursing acknowledged the shortage and noted that it could potentially lead to increased readmission rates. The facility's policy, revised in August 2006, requires an RN or LPN to be on duty 24 hours a day, seven days a week, which was not adhered to during the specified dates.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards in the storage, preparation, distribution, and serving of food, as observed in their only kitchen. During an inspection, it was noted that items in the walk-in refrigerator were not labeled with open or preparation dates. Specifically, three trays of unlabeled drinks, an opened milk jug, a small jar of jalapenos, a small jar of mayonnaise, and a small squeeze bottle of mayonnaise were found without labels indicating when they were opened. This lack of labeling could potentially lead to foodborne illnesses among residents who consume meals prepared in the kitchen. Additionally, a dented can of tomatoes was found in the dry storage area, mixed with other canned goods, despite the facility's policy that dented cans should be placed on a designated shelf for return to the vendor. The Dietary Manager acknowledged that all open foods in the refrigerator should be labeled with the date opened and that dented cans should be identified and separated upon delivery. The failure to label open items and the presence of a dented can in the storage area were identified as risks for foodborne illness.
Deficiency in Shower Room Water Temperature Management
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents in two shower rooms. In Shower Room 1, the water temperature was recorded at 96.8 degrees Fahrenheit, which is below the recommended range. In Shower Room 2, the water temperature was excessively high at 124.1 degrees Fahrenheit, exceeding the maximum safe limit of 110 degrees Fahrenheit. The Maintenance Supervisor, who had been in the position for only two weeks, confirmed these temperatures during observations and interviews. Additionally, it was revealed that the facility did not maintain water temperature logs, which are required to ensure consistent monitoring and safety. Interviews with the Administrator (ADM) and Director of Nursing (DON) indicated that no residents had reported injuries due to the water temperature issues, and there were no recorded grievances or concerns related to water temperature in the past six months. However, the facility's policies from 2003 and 2016 clearly outlined the need for regular temperature checks and logs to ensure a safe environment. The lack of adherence to these policies and the absence of water temperature logs contributed to the deficiency, potentially affecting the residents' comfort and safety.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for residents to maintain their independence and safety. The resident, a 64-year-old female with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and paraplegia, was found to have her call light on the floor under the bed. This situation was discovered during an observation and interview, where the resident expressed concern about not being able to call for help if needed. The resident's care plan did not address the use of the call light, which is a critical oversight given her condition and need for assistance. Interviews with the CNA and the DON revealed that the call light's inaccessibility was not noticed until the surveyor's observation. The CNA, who was responsible for the resident, was unaware of how the call light ended up on the floor but acknowledged the potential risk of falls if the resident attempted to get assistance without it. The DON emphasized the importance of ensuring call lights are accessible and mentioned that charge nurses monitor this during morning rounds. However, the facility's policy, which requires call lights to be within reach, was not adhered to in this instance.
Failure to Provide Special Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who required them during meal service. Specifically, the staff did not ensure that the resident, who was diagnosed with muscle wasting, atrophy, and feeding difficulties, received a built-up spoon and a straw as indicated in her care plan. During a dining observation, the resident was given a regular fork instead of the required built-up spoon and was not provided a straw, which was contrary to her care plan and meal ticket instructions. The resident expressed that she found the built-up spoon uncomfortable and had requested a regular fork, stating she no longer needed a straw. However, the Dietary Manager could not recall when this request was made and acknowledged that not providing the built-up spoon or straw could make eating and drinking difficult for the resident. The facility's policy on adaptive eating devices requires the dietary department to sanitize and place the necessary utensils on the resident's tray, which was not followed in this instance.
Failure to Ensure Safe Storage of Residents' Food Items
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of residents' food items in personal refrigerators, specifically in one resident's room. Observations revealed that the personal refrigerator contained sliced summer sausage in an unlabeled and undated zip-lock bag. This was confirmed during an interview with a CNA, who acknowledged the presence of the unlabeled and undated food item. The Director of Nursing confirmed that perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent consumption of spoiled foods. However, it was noted that the night shift nurses, who were responsible for overseeing this task, were not currently monitoring it. The facility's policy, revised in October 2017, requires perishable foods to be stored in resealable containers with labels indicating the resident's name, the item, and the use-by date.
Inaccurate Documentation of Resident Code Status
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented in accordance with accepted professional standards and practices for one resident. Specifically, there was a discrepancy in the documentation of the resident's code status. The resident's admission record and consolidated orders indicated a full code status, while a care plan conference document incorrectly recorded the resident as having a DNR status. This inconsistency was identified during an interview with the facility's administrator and the MDS coordinator, who acknowledged the error in the care plan conference documentation. The MDS coordinator noted that charge nurses rely on the code status book and orders for accurate information, rather than care plan conferences.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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